have heard, “If you have to have diabetes, now is the best time in history to be diagnosed." There have been great advances in diabetes management. Prior to 1996, the only medication options were animal derived insulins, sulfonylureas, and biguinide/ Metformin. We now have over 10 classes of diabetes drugs. Meters were large and bulky, requiring large amounts of blood—remember the “large hanging drop?" Lancing devices looked like small guillotines. Early meters had to be plugged in to warm up for 5 minutes. We have amassed vast knowledge over the past 20 years and the fact that diabetes is no longer solely a deficiency of the pancreas—recall Dr. DeFronzo’s Ominous Octet.
Despite these incredible advances, in my opinion (since this is my post), the biggest challenge is motivating my patients and helping them understand the seriousness of their disease—and I’ve been at this a long time! I took the first CDE exam—if are not aware of that date, please look it up. I was the only diabetes educator at a large 350 bed community hospital working with a 3 person endocrine team back before the turn of the century when people were admitted for a 5 day in-patient stay when diagnosed with diabetes. Since that time, I have spent at least 75% of my time in diabetes training, care, and management. I am not a novice at this.
The biggest challenge is motivating my patients and helping them understand the seriousness of their disease.
The majority of my time and effort is spent working with my patients and convincing them to follow the recommendations of their primary care provider, the RD, exercise therapist, pharmacist, or me as the RN/CDE. Usually I can negotiate with them. For example, if they are not interested in an intensive insulin regimen, we often mutually agree to start with one injection of a basal insulin daily. If they are not excited about multiple finger sticks for self-monitoring of blood glucose (SMBG), we can start with one a day until they become more comfortable and see the benefit of knowing their numbers. You get the idea.
Recently, I was consulted on a patient in his 30s who has had type 2 diabetes mellitus for several years. The actual onset date is unknown. When I first met him he had an A1C of more than 10%. I spent time with him as an inpatient and met with him several times after discharge. We discussed all aspects of the AADE7 at some time throughout our appointments. Up front he told me he would be unable to SMBG due to fear of needles. During several visits, I put all my problem solving, interviewing and motivational skills to the test, but unfortunately, he stopped attending our appointments. He recently was admitted again but this time his A1C was even higher. I went to visit and he continues to refuse glucose monitoring and insulin injections. I tried everything I could think of but his fear of needles outweighs his desire for treatment. He even knows he will eventually die without insulin.
This young man continues to cross my mind as I ponder how I can best help him. I think I will recommend a psychiatric consult for depression.
I think situations like this are common frustrations for CDEs, and I want to open it up for discussion. We can all spit out what to do and when and how to do it, but our biggest challenge is getting the patient to do it.
About the Author
Barbara Walz is an RN, BSN and has been a certified diabetes educator since 1986. Since 2000, Barbara has coordinated a multi-site diabetes study examining the macro-vascular effects of diabetes at the South Texas Veterans’ Healthcare System under the supervision of Dr. Ralph DeFronzo.